Patient-Centered Medical Home Initiatives Expanded In 2009-13: Providers, Patients, And Payment Incentives Increased

Abstract

Patient-centered medical home initiatives are central to many efforts to reform the US health care delivery system. To better understand the extent and nature of these initiatives, in 2013 we performed a nationwide cross-sectional survey of initiatives that included payment reform incentives in their models, and we compared the results to those of a similar survey we conducted in 2009. We found that the number of initiatives featuring payment reform incentives had increased from 26 in 2009 to 114 in 2013. The number of patients covered by these initiatives had increased from nearly five million to almost twenty-one million. We also found that the proportion of time-limited initiatives-those with a planned end date-was 20 percent in 2013, a decrease from 77 percent in 2009. Finally, we found that the dominant payment model for patient-centered medical homes remained fee-for-service payments augmented by per member per month payments and pay-for-performance bonuses. However, those payments and bonuses were higher in 2013 than they were in 2009, and the use of shared-savings models was greater. The patient-centered medical home model is likely to continue both to become more common and to play an important role in delivery system reform.

Full text

At the Intersection of Health, Health Care and Policy
doi: 10.1377/hlthaff.2014.0351
, 33, no.10 (2014):1823-1831Health Affairs
And Payment Incentives Increased 13: Providers, Patients,−Patient-Centered Medical Home Initiatives Expanded In 2009
Samuel T. Edwards, Asaf Bitton, Johan Hong and Bruce E. Landon
Cite this article as:
http://content.healthaffairs.org/content/33/10/1823.full.html
available at:
The online version of this article, along with updated information and services, is
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php
http://content.healthaffairs.org/subscriptions/etoc.dtlE-mail Alerts :
http://content.healthaffairs.org/subscriptions/online.shtmlTo Subscribe:
written permission from the Publisher. All rights reserved.
mechanical, including photocopying or by information storage or retrieval systems, without prior
may be reproduced, displayed, or transmitted in any form or by any means, electronic orAffairs HealthFoundation. As provided by United States copyright law (Title 17, U.S. Code), no part of
by Project HOPE - The People-to-People Health2014Bethesda, MD 20814-6133. Copyright ©
is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600,Health Affairs
Not for commercial use or unauthorized distribution
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

By Samuel T. Edwards, Asaf Bitton, Johan Hong, and Bruce E. Landon
Patient-Centered Medical Home
Initiatives Expanded In 2009–13:
Providers, Patients, And Payment
Incentives Increased
ABSTRACT
Patient-centered medical home initiatives are central to many
efforts to reform the US health care delivery system. To better
understand the extent and nature of these initiatives, in 2013 we
performed a nationwide cross-sectional survey of initiatives that included
payment reform incentives in their models, and we compared the results
to those of a similar survey we conducted in 2009. We found that the
number of initiatives featuring payment reform incentives had increased
from 26 in 2009 to 114 in 2013. The number of patients covered by these
initiatives had increased from nearly five million to almost twenty-one
million. We also found that the proportion of time-limited initiatives—
those with a planned end date—was 20 percent in 2013, a decrease from
77 percent in 2009. Finally, we found that the dominant payment model
for patient-centered medical homes remained fee-for-service payments
augmented by per member per month payments and pay-for-performance
bonuses. However, those payments and bonuses were higher in 2013 than
they were in 2009, and the use of shared-savings models was greater. The
patient-centered medical home model is likely to continue both to
become more common and to play an important role in delivery system
reform.
Since the passage of the Affordable
Care Act, payers and providers have
been increasing their efforts to re-
organize the health care delivery
system, with the goal of increasing
quality, improving patients’experiences, and re-
ducing costs. Central to many of these efforts is
the creation of an advanced primary care system
that seeks to increase the value of care through a
tighter focus on access, prevention, and coordi-
nation.1,2 The current primary care payment sys-
tem rewards providers for delivering high vol-
umes of services instead of comprehensive,
whole-person care.3This leads to, among other
things, increasing physician burnout4and an
impending workforce shortage.5–7
Many efforts to reorganize and improve pri-
mary care focus on implementing the patient-
centered medical home care model. This model
has been endorsed by all major organizations of
US primary care physicians.8It is based on the
fundamental tenets of primary care, including
comprehensive care for the majority of health
problems; long-term, person-focused care; serv-
ing as the first contact for new issues; and coor-
dinated care.9
Operationally, patient-centered medical
homes typically use multidisciplinary teams
and advanced tools such as enhanced health in-
formation technology, chronic disease regis-
tries, and online patient portals to proactively
manage the full spectrum of patients’needs.
These primary care practices also feature an ex-
plicit focus on managing care transitions, often
doi: 10.1377/hlthaff.2014.0351
HEALTH AFFAIRS 33,
NO. 10 (2014): 1823–1831
©2014 Project HOPE—
The People-to-People Health
Foundation, Inc.
Samuel T. Edwards (ste007@
mail.harvard.edu) is a fellow at
the Veterans Affairs Boston
Healthcare System and
Harvard Medical School, both
in Boston, Massachusetts.
Asaf Bitton is an assistant
professor of medicine and
healthcarepolicyatHarvard
Medical School and Brigham
and Women’sHospital,in
Boston. He is also a core
faculty member at Harvard
Medical School’sCenterfor
Primary Care.
Johan Hong is a research
assistant in the Department
of Health Care Policy, Harvard
Medical School.
Bruce E. Landon is a
professor of health care
policy and medicine in the
Department of Health Care
Policy, Harvard Medical
School, and in the Division of
General Medicine and Primary
Care, Beth Israel Deaconess
Medical Center, in Boston.
October 2014 33:10 Health Affairs 1823
Patient-Centered Medical Homes
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

using dedicated care managers, and they fre-
quently integrate behavioral health care into pri-
mary care.10
Patient-centered medical home initiatives are
often organized by health plans, states, or multi-
stakeholder groups. The goal of the initiatives is
to create the appropriate environment for prima-
ry care practices to transform themselves into
patient-centered medical homes. To accomplish
this, the initiatives often build learning collabo-
ratives among multiple participating practices,
hire transformation coaches to work with prac-
tices, and reform physician payment to support
advanced primary care services.
We characterized patient-centered medical
home initiatives throughout the United States
in 2009.11 At that point we found twenty-six ini-
tiatives with payment reforms that included over
14,000 providers caring for nearly five million
patients. Since then, peer-reviewed evaluations
of patient-centered medical home initiatives
have shown mixed results in terms of quality
of care and overall costs.12–21 Nevertheless, these
initiatives have continued to expand across the
country, including within Medicare.22–26
To provide a better understanding of the mag-
nitude of the expansion of patient-centered
medical homes, and of trends in payment meth-
odologies and approaches to practice transfor-
mation, we report the results of a follow-up na-
tionwide survey of patient-centered medical
home initiatives.
Study Data And Methods
Sample Identif ication As we did in our previ-
ous survey, in 2013 we identified and surveyed all
patient-centered medical home initiatives in the
United States that included payment reform in-
centives.We defined these incentives as the pro-
vision of additional payments from an external
payer to primary care practices to support medi-
cal home functions.
To comprehensively identify candidate initia-
tives for this survey, we started with the initia-
tives that we included in our previous survey and
additional programs that we identified at that
time that did not qualify for the previous survey.
We then reviewed existing databases of patient-
centered medical home initiatives such as those
maintained by the Patient-Centered Primary
Care Collaborative27 and the National Academy
for State Health Policy.28
We next performed a literature search of
MEDLINE, Embase, and CINAHL to identify ar-
ticles published between January 1, 2000, and
December 31, 2012, that used the terms patient-
centered medical home and medical home. We also
searched the Internet for articles, using the same
two terms. Finally, we contacted known experts
in the field, including representatives of state
Medicaid agencies and national commercial
health plans.
We included in our survey all initiatives that
were active as of February 1, 2013, and those from
our previous survey that had ended after January
1, 2010. We excluded programs directed toward
specific medical conditions such as HIV or dia-
betes. However, we included a small number of
programs that targeted the elderly or patients
with multiple chronic diseases.
Initiatives were defined as distinct programs
that included one or more payers operating in
a distinct market area or state. Thus, a single
national program that operated in more than
one state was considered to be multiple pro-
grams because the details and size of the initia-
tives and the market contexts differed.
Instrument Development And Data Col-
lection We developed written, Web-based, and
telephone versions of the survey instrument to
give respondents flexibility. The survey instru-
ment used closed-ended questions. It allowed
respondents to skip questions that were not ap-
plicable, based on their previous responses.
We asked respondents to provide for their pa-
tient-centered medical home initiative the start
and end dates and the numbers of participating
practices, physicians, and patients. We also
asked respondents to identity key initiative
stakeholders. And we asked respondents to de-
scribe the process that their initiative used to
determine which practices could participate
and if the initiative used formal patient-centered
medical home recognition standards such as
those of the National Committee for Quality As-
surance (NCQA), described below.
The survey asked about payment methodolo-
gies and how initiatives facilitated practice trans-
formation, including the use of learning collab-
oratives in which participating practices can
learn different approaches to transforming care
from each other and from recognized experts.
The survey also asked respondents to indicate
whether their initiative used consultants or
coaches to work directly with practices, and
whether plans for program evaluation were in
place.
Survey Administration Procedures We
used e-mail or telephone to contact leaders of
each of the patient-centered medical home ini-
tiatives that we had identified to determine who
in the initiative would be the most appropriate
respondent or respondents for our survey.
Respondents were typically physician leaders
or senior administrators.
After pretesting the survey instrument with
five participants by telephone, we sent the re-
Patient-Centered Medical Homes
1824 Health Affairs October 2014 33:10
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

maining participants an e-mail invitation to the
Web-based survey, giving them the option of
scheduling a phone interview or receiving a writ-
ten version instead of completing the survey
online. For patient-centered medical home ini-
tiatives that operated in multiple areas, we col-
lected information that applied to all markets
with a single survey and then obtained individual
market-specific information with additional
phone interviews.
Stat is ti c al Ana lysi s We classified the initia-
tives into three groups based on payer type. Ini-
tiatives in the first group had a single commercial
payer. We subdivided this group into small ini-
tiatives (those with fewer than 25,000 patients)
and large initiatives (those with 25,000 patients
or more).
Initiatives in the second group served only the
Medicaid population. This group included initia-
tives organized by health plans that focused ex-
clusively on the Medicaid population.
Initiatives in the third group had multiple
payers. These payers included multiple commer-
cial health plans and, in many cases, Medicare
and Medicaid.
We present descriptive statistics and compare
features of initiatives in these three groups
throughout the United States.We also estimated
multivariable regression models to examine dif-
ferences in per member per month payments
among initiative groups, after we controlled
for other initiative characteristics.
2009 Survey In 2009, participants were iden-
tified using the same approach as described
above, and data were collected in the same do-
mains through the use of structured interviews.
For the data comparisons between 2009 and
2013 presented here, the survey questions were
identical.
Li mi tati o ns There are several limitations to
our work. First, despite our efforts, it is possible
that we did not identify some patient-centered
medical home initiatives. However, these would
likely be small, time-limited programs—those
with a planned end date—that would have a min-
imal impact on our aggregate results.
Second, we generally relied on a single infor-
mant from each initiative. These people might
not have had complete knowledge of all aspects
of the initiative. We did, however, encourage
respondents to seek information from addition-
al members of their organizations, and we spent
a substantial amount of time confirming re-
sponses from other sources when they were
available.
Finally, our analysis is only descriptive and
was performed at the level of the patient-
centered medical home initiative, not at the level
of the participating practices. Thus, we cannot
comment on how much individual practices have
been transformed or how the initiatives affected
quality of care, utilization, or patients’expe-
riences.
Study Results
Of the 172 patient-centered medical home initia-
tives that we identified nationally, 119 included
payment reform as a part of the model and thus
met our inclusion criteria. Of these 119 initia-
tives, 114 (96 percent) responded to our survey.
Exhibit 1 shows the breakdown of these 114 ini-
tiatives into the payer groups. Collectively, the
initiatives included 63,011 providers who cared
for 20,764,676 patients.
Initiative Scope Initiatives varied from small
pilots with only a few practices to statewide pro-
grams that involved large numbers of patients.
Small single commercial payer initiatives had a
median of 3,896 patients and typically included
a small number of practices (the median was
four). Only 8 percent of these programs were
time limited (Exhibit 1). Seventy-five percent
of health plans that sponsored initiatives in this
group had no more than a 20 percent share of the
market in their region. The sponsoring health
plans also typically included only a single line of
business in their initiative (50 percent included
only commercial coverage, and 50 percent only
Medicare Advantage).
In contrast, large single commercial payer
initiatives had a median of 160,000 patients
(Exhibit 1). These initiatives often included most
or all of the practices in a specific region or state
(median number of practices: 105; data not
shown). The health plans that sponsored this
group of initiatives tended to have a larger mar-
ket share (median: 21–40 percent), and 54 per-
cent of the plans included two or more lines of
business in their initiatives. None of the initia-
Patient-centered
medical home
initiatives are often
organized by health
plans, states, or
multistakeholder
groups.
October 2014 33:10 Health Affairs 1825
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

tives in this group was time limited.
Eleven of the twenty-three Medicaid-only ini-
tiatives were large statewide efforts that had a
median of 224,040 patients and that were run
directly by state Medicaid agencies. Some of
these programs had evolved from existing pri-
mary care case management programs.
Five of the Medicaid-only initiatives used re-
gional entities such as regional care collabora-
tive organizations to provide care coordination
and advanced data management capabilities or
to facilitate practice transformation efforts in
different parts of the state. The remaining initia-
tives in this category were smaller, with a median
of fewer than 20,000 patients. Three of the ini-
tiatives were state-run pilot programs; nine were
Medicaid managed care programs. Overall,
only three Medicaid-only initiatives were time
limited.
Initiatives with multiple payers included a me-
dian of 187,343 patients (Exhibit 1). They also
included a median of six health plans (inter-
quartile range: 4–7) and sixty-eight practices
(data not shown). These initiatives were fre-
quently statewide. The combined market share
of participating health plans was substantially
higher (median: greater than 60 percent) than
the market share of plans that sponsored single-
payer initiatives. Eighty-five percent of the com-
mercial payers involved in multipayer initiatives
included at least two lines of business. State Med-
icaid programs participated in 81 percent of mul-
tipayer initiatives.
In contrast to other initiatives, most multi-
payer initiatives (81 percent) were time limited
(Exhibit 1). However, the 76 percent of initia-
tives that included Medicare through the Com-
prehensive Primary Care and the Multi-Payer
Advanced Primary Care Initiatives have the po-
tential to continue beyond their end date.
Recognition And Practice Entry Or Selec-
tion Requirements Recognition of participat-
ing practices as patient-centered medical homes
using established standards was required by
69 percent of the initiatives (Exhibit 2). Fifty-
five percent of the initiatives required practices
to be recognized prior to entering the initiative.
Eighty-six percent used external standards—
such as those of the NCQA—for recognition;
the remainder required recognition using inter-
nally developed standards.
NCQA recognition was always accepted as ex-
ternal recognition. However, several initiatives
also accepted recognition from other organiza-
tions such as URAC (formerly known as the Uti-
lization Review and Accreditation Commission)
or the Joint Commission.
Among initiatives that required NCQA recog-
nition, 91 percent used level 3 as the target level,
and a mean of 69 percent of practices in the
initiatives achieved that level (Exhibit 2). Other
criteria that were used to select practices to par-
ticipate in an initiative included participating in
previous quality improvement efforts (41 per-
cent) or the presence of existing chronic disease
registries (48 percent) and using electronic
Exhibit 1
Characteristics Of 114 Patient-Centered Medical Home Initiatives That Included Payment Reform Incentives, 2013
Type of initiative, by payer
Single commercial payer
Characteristic
Small
(n=41)
Large
(n=29)
Medicaid only
(n=23)
Multiple payers
(n=21) All (N=114)
Providers (total) 2,149 21,870 29,213 9,369 63,011
Providers (median) 104a850b778c276d300e
Patients (total) 231,688 7,550,483 7,542,188 5,440,317 20,764,676
Patients (median) 3,896f160,000g78,000h238,277i42,003j
Health plan market share in region
0–20% 75% 42% 88% 0% 43%
21–40% 17 17 13 0 12
41–60% 8 38 0 19 22
More than 60% 0 4 0 81 23
Time-limited initiative 8 0 13 81 20
Includes safety-net practices 30 59 100 57 57
Includes children 38 93 91 100 74
SOURCE Authors’analyses of survey data provided by patient-centered medical home initiatives. NOTES Smallsinglecommercialpayer
initiatives are those with fewer than 25,000 patients. Large single commercial payer initiatives are those with 2 5,000 patients or more.
For health plan results, Medicaid data reflect only Medicaid managed care plans. Time-limited initiatives are those with a planned end
date. aInterquartile range (IQR): 29–199. bIQR: 397–1,270. cIQR: 68–1,800. dIQR: 136–385. eIQR: 101–928. fIQR: 1,870–8,474. gIQR:
54,510–297,768. hIQR: 17,000–500,000. iIQR: 85,000–233,990. jIQR: 5,987–194,552.
Patient-Centered Medical Homes
1826 Health Affairs October 2014 33:10
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

health records (59 percent; data not shown).
Payments All but two of the initiatives used
standard or enhanced fee-for-service payments
for office visits, with enhanced payments includ-
ing either higher rates or reimbursement for
additional services such as care coordination.
These payments were augmented with pay-for-
performance bonuses (8 percent), per member
per month payments to practices (29 percent),
or both (55 percent; Exhibit 3)—proportions
that were similar to those seen in 2009.11 Approx-
imately 16 percent of the initiatives used only
enhanced fee-for-service payments that included
additional billing codes for services such as care
coordination.
In 32 percent of the initiatives, per member
per month payments were adjusted for patients’
characteristics such as age, sex, and preexisting
conditions (Exhibit 3). However, this was less
common in small single commercial payer ini-
tiatives (8 percent). Half of the initiatives adjust-
ed the per member per month payment for the
level of patient-centered medical home recogni-
tion achieved, and 19 percent adjusted it for qual-
ity performance.
Among the initiatives that made a per member
per month payment, the median amount was
$4.90, with an interquartile range of $3.00–
$8.00 (Exhibit 3). The median payment was low-
er in small single commercial payer initiatives
($4.00) and Medicaid-only initiatives ($3.62)
than in multipayer initiatives ($7.00).
In the six initiatives that made a per member
per month payment only for patients who had
multiple chronic diseases, the median payments
were substantially higher than those for the oth-
er programs (median: $17; interquartile range:
$10.53–$35.00; data not shown). In initiatives
that risk-adjusted the payments by patients’
characteristics, the average payment was higher
than that for programs that did not use risk ad-
justment (median: $6.50; IQR: $3.68–$24.00).
Seventeen percent of the initiatives paid for
care coordinators separately from the per patient
per month payments to practices (Exhibit 3).
However, this was less common in small single
commercial payer initiatives (5 percent). In a
multivariate regression analysis that controlled
for initiatives that risk-adjusted their per mem-
ber per month payments or paid care coordina-
Exhibit 2
Practice Recognition And Transformation Support Used By 114 Patient-Centered Medical Home Initiatives That Included
Payment Reform Incentives, 2013
Type of initiative, by payer
Single commercial payer
Type of recognition or support Small Large
Medicaid
only
Multiple
payers All
Recognition
Formal recognition required 73% 83% 48% 62% 69%
On practice entrya45 60 73 54 55
After practice entrya55 40 28 47 45
Recognition typea
NCQA or other externala100 80 64 85 86
Internala02036 1515
Recognition application fee supporta0 31 9 24 14
Pay for recognition levela,b 38 45 30 24 35
Target level NCQA 3c94 100 67 83 91
Practices that achieved NCQA level 3 (mean)c81 76 57 54 69
Transformation support
Use practice consultants 8 55 61 91 46
Use learning collaboratives 15 52 61 95 49
Data sharing between payers and practices 98 97 83 100 95
Data sharing among practices 68 86 57 81 73
SOURCE Authors’analyses of survey data provided by patient-centered medical home initiatives. NOTES Sample sizes for each payer
category are provided in Exhibit 1, and small and large single commercial payer initiatives are defined in the Exhibit 1 notes. The 2011
National Committee for Quality Assurance (NCQA) patient-centered medical home recognition standards are based on a self-
administered survey that covers six domains of medical home function: enhance access and continuity, identify and manage
patient populations, plan and manage care, provide self-care support and community resources, track and coordinate care, and
measure and improve performance. Within each domain there are required elements necessary for recognition as a patient-
centered medical home, and all answers are scored. There are three levels of NCQA recognition (1 is the lowest; 3 is the highest),
based on the total number of points calculated from the survey responses. aAmong practices that required any recognition. bPer
member per month payments are increased for higher levels of patient-centered medical home recognition. cAmong practices that
require NCQA recognition.
October 2014 33:10 Health Affairs 1827
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

tors directly, the payments for initiatives with
multiple payers remained larger than the pay-
ments of initiatives paid by commercial payers
or Medicaid only (p<0:01).
Sixty-four percent of the initiatives used pay-
for-performance bonuses (Exhibit 3). These bo-
nuses were most commonly based on quality
metrics such as measures in the Healthcare Ef-
fectiveness Data and Information Set (97 per-
cent) and on measures of downstream utiliza-
tion, such as emergency department visits and
inpatient hospitalizations (85 percent). Twenty-
one percent of the initiatives used measures of
patient experience to determine pay-for-perfor-
mance bonuses.
Forty-four percent of all initiatives and 57 per-
cent of multipayer initiatives used shared-sav-
ings payment models (Exhibit 3). In these ini-
tiatives, practices that reduce the rate of cost
growth for patients to whom they provide prima-
ry care services as compared to a control popula-
tion can share in the potential savings with
health plans.
Tr an sf o rm ati o n A nd Eval uat io n Paid prac-
tice consultants were used by 46 percent of the
initiatives, and learning collaboratives were used
by 49 percent (Exhibit 2). Thirty-seven percent
of the initiatives used both paid consultants and
learning collaboratives (Exhibit 4).
Notably, almost all multipayer initiatives used
practice consultants (91 percent) and learning
collaboratives (95 percent; Exhibit 2). In con-
trast, small single commercial payer initiatives
used these approaches much less commonly
(8 percent and 15 percent, respectively). Nine-
ty-five percent of all initiatives shared data be-
tween payers and practices to help practices
identify high-risk patients and monitor utiliza-
tion. Seventy-three percent shared data internal-
ly to identify best practices.
Ninety-two percent of the initiatives were
planning to conduct formal program evaluations
(Exhibit 4). All multipayer initiatives were plan-
ning to use independent external evaluators, but
this was the case with only 2 percent of small
single commercial payer and 18 percent of large
single commercial payer initiatives (data not
shown).
The most common evaluation domains includ-
ed clinical quality (98 percent), costs or utiliza-
tion (99 percent), patient satisfaction (76 per-
cent), and physician satisfaction (69 percent;
data not shown). Only 40 percent of all initia-
tives planned to assess staff satisfaction. How-
ever, 86 percent of multipayer initiatives
planned to assess staff satisfaction.
Original Pilots Of the twenty-six patient-
centered medical home initiatives that we iden-
Exhibit 3
Payment Methods Used By 114 Patient-Centered Medical Home Initiatives That Included Payment Reform Incentives, 2013
Type of initiative, by payer
Single commercial payer
Payment method Small Large
Medicaid
only
Multiple
payers All
Fee-for-service (FFS) only 3% 0% 35% 0% 8%
FFS and pay-for-performance bonus 0 30 0 5 8
FFS and per member per month (PMPM) payment 33 7 35 43 29
FFS, pay-for-performance bonus, and PMPM payment 65 63 30 52 55
PMPM payment (median)a$4.00b$5.00c$3.62d$7.00e$4.90f
PMPM payment adjusted for:
Patients’characteristicsg8% 43% 47% 55% 32%
NCQA level 69 52 33 20 50
Quality performance 23 33 0 8 19
PMPM payment for patients with multiple chronic diseases only 5 0 20 10 8
Pay-for-performance bonus 65 93 30 57 64
Based on clinical quality 100 100 71 100 97
Based on patient experience 8 15 29 58 21
Based on downstream utilization 92 85 71 75 85
Shared savings 38 45 44 57 44
Up-front payment 5 21 4 19 12
Initiative pays for care coordinators separately from PMPM payments 5 21 30 19 17
SOURCE Authors’analyses of survey data provided by patient-centeredmedical home initiatives. NOTES Sample sizes for each payer category are provided in Exhibit 1, and
small and large single commercial payer initiatives are defined in the Exhibit 1 notes. National Committee for Quality Assurance (NCQA) levels are explained in the
Exhibit 2 notes. aExcludes initiatives that make per member per month payments only for patients with multiple chronic diseases. bInterquartile range (IQR): $3.50–
$6.50. cIQR: $2.50–$8.00. dIQR: $2.44–−$8.87. eIQR: $5.18–$24.00. fIQR: $3.00–$8.00. gIncluding age, sex, and preexisting conditions
Patient-Centered Medical Homes
1828 Health Affairs October 2014 33:10
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

tified in 2009, nine (35 percent) were still oper-
ating in their previous form in 2013. Thirteen
more had joined other initiatives. Respondents
representing the four initiatives that ended be-
fore 2013 cited challenges involved in knowing
which patients they were responsible for (and for
whom they would receive extra payments) and
unachievable shared-savings targets as reasons
why the initiatives were terminated.
Overall, patients in the patient-centered med-
ical home initiatives quadrupled from nearly five
million in 2009 to almost twenty-one million in
2013 (Exhibit 4). In addition, the proportion of
time-limited programs decreased from 77 per-
cent to 20 percent, the number of multipayer
initiatives increased from nine to twenty-one,
and shared savings emerged as a new payment
model.11
Discussion
Findings from this 2013 national survey of pa-
tient-centered medical home initiatives that in-
cluded payment reform incentives indicate sev-
eral important developments since our 2009
survey. First, there has been fourfold growth
nationally in the number of these initiatives
and the number of patients served by them.
Patient-centered medical home initiatives can
now be found in forty-four states, compared to
eighteen states in 2009. Second, many more of
the initiatives now are open-ended, not time-
limited. Third, the dominant payment model
for the initiatives remains typical fee-for-service
payments augmented by per member per month
payments and pay-for-performance bonuses.
However, per member per month payments are
higher than in the past, and shared-savings mod-
els are increasingly common. These changes
make the initiatives more responsive to changes
in the total costs of care, in a manner similar
to accountable care organizations. Finally, the
initiatives that included payment reform incen-
tives have evolved from mostly small and time-
limited demonstration programs to larger, more
open-ended efforts. Current patient-centered
medical home efforts are truly initiatives instead
of pilots.
Several large commercial payers indicated that
their patient-centered medical home initiative
was merely an early step toward fundamentally
reforming payment for primary care throughout
their networks. Moreover, through the Afford-
able Care Act, the Centers for Medicare and Med-
icaid Services has the authority to expand the
duration and scope of its multipayer demonstra-
tion projects if they reach prespecified quality
and cost outcome targets.
The longer-term, more open-ended nature of
the current patient-centered medical home ini-
tiatives suggests a recognition of the importance
of sustained investment in the primary care in-
frastructure. It also recognizes the difficulty of
transforming in a short period of time primary
care practices that evolved into their current
state during decades of fee-for-service incen-
tives. It is likely that changing practice behavior
and culture will take substantial effort and time.
We also observed heterogeneity in initiatives’
approaches to promoting practice transforma-
tion. For instance, multipayer initiatives gener-
ally made higher per member per month pay-
ments, more frequently used both learning
collaboratives and practice consultants, and
were more likely to be planning more compre-
hensive program evaluations. In contrast, small
single commercial payer initiatives used consul-
tants and learning collaboratives less frequently,
made lower per member per month payments,
and more frequently required NCQA recogni-
tion.
The increase in the average per member per
Exhibit 4
Comparison Of Patient-Centered Medical Home Initiatives That Included Payment Reform Incentives, 2009 And 2013
Characteristic 2009 (n= 26) 2013 (n= 114)
Number of patients 4,956,070 20,764,676
Number of patients per initiative (median) 34,500 42,003
Time-limited initiatives 77% 20%
Multipayer initiatives 9% 21%
Patients per multipayer initiatives (median) 39,000 187,343
Use shared savings 0% 44%
Range of per member per month payment $0.50–$9.00 $0.25–$60.00
Use learning collaboratives and consultants 15% 37%
Plan for program evaluation 40% 92%
SOURCE Authors’analyses of survey data provided by patient-centered medical home initiatives. NOTE Time-limited initiatives are
thosewithaplannedenddate.
October 2014 33:10 Health Affairs 1829
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

month payments since 2009 appears modest.
However, this difference likely underestimates
the aggregate difference in the amount of addi-
tional payments that practices in some initiatives
receive. In multipayer initiatives, particularly
those that include Medicare, the participating
payers cover a larger proportion of the patients
in the local market, thus generating larger aggre-
gate payments to practices.
For example, if a five-physician practice with
10,000 patients participates in a multipayer ini-
tiative that covers half of their patients, and the
practice receives the median per member per
month payment of $7.00, then the practice
would receive $35,000 per month. In addition,
the practice could receive a pay-for-performance
bonus of up to $10 per member per month, fur-
ther increasing non-visit-based revenue and pos-
sible shared savings.
In contrast, small single commercial payer ini-
tiatives generally represent a small proportion of
the local market. Thus, a practice similar in size
to the practice in the example above that partici-
pated in such an initiative might receive the me-
dian $4.00 per member per month payment for
only 5 percent of its patients, for a total of $2,000
per month.
Recent evaluations of early patient-centered
medical home initiatives have yielded mixed re-
sults.17,19–21,29 However, focusing on the results of
these generally small time-limited pilots risks
prematurely abandoning efforts to reform the
primary care system. Meanwhile, the patient-
centered medical home model continues to
evolve, and implementers learn from prior expe-
rience how to improve current and future ini-
tiatives.
In addition, early initiatives did not include
any overt incentives or targeted learning to de-
crease costs and utilization. The increasing use
of utilization-based pay-for-performance met-
rics, shared-savings programs, and transforma-
tion efforts that focus explicitly on cost reduction
may provide incentives and tools for practices
to more actively manage total medical expen-
ditures.
Our study demonstrates that patient-centered
medical home initiatives are highly heteroge-
neous, and it is likely that some approaches
will be more successful than others. Most initia-
tives now include evaluation plans. Therefore,
current initiatives likely will highlight what
elements of the patient-centered medical home
model are most important to achieving measur-
able success.
Conclusion
Patient-centered medical home initiatives that
include payment reform incentives are rapidly
expanding across the United States. Supported
by private and public payers, the initiatives cover
almost twenty-one million patients. Current ini-
tiatives are heterogeneous, but overall they are
becoming larger, are paying higher fees, and are
engaged in more risk sharing with practices.
The growth in the number and size of initiatives
suggests that there is substantial interest in
the patient-centered medical home as a model
of reform and that a wide group of payers recog-
nizes that the existing primary care system re-
quires additional investment and transfor-
mation. ▪
An earlier version of this article was
presented at the Society for General
Internal Medicine National Meeting in
San Diego, California, April 24–27, 2014,
and at the AcademyHealth Annual
Research Meeting in San Diego, June 8–
10, 2014. This research was funded by a
grant from the Commonwealth Fund.
SamuelEdwardsisafellowatthe
Veterans Affairs Boston Healthcare
System. Asaf Bitton serves part-time as
a senior adviser to the Comprehensive
Primary Care initiative at the Center for
Medicare and Medicaid Innovation
(CMMI). The ideas expressed in this
article are solely those of the authors
and do not represent any official
position of the CMMI or the Department
of Veterans Affairs. The authors thank
all of the respondents to the survey for
participating.
It is likely that
changing practice
behavior and culture
will take substantial
effort and time.
Patient-Centered Medical Homes
1830 Health Affairs October 2014 33:10
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from

NOTES
1Grundy P, Hagan KR, Hansen JC,
Grumbach K. The multi-stakeholder
movement for primary care renewal
and reform. Health Aff (Millwood).
2010;29(5):791–8.
2Sandy LG, Bodenheimer T, Pawlson
LG, Starfield B. The political econo-
my of U.S. primary care. Health Aff
(Millwood). 2009;28(4):1136–45.
3Bodenheimer T, Berenson RA,
Rudolf P. The primary care–specialty
income gap: why it matters. Ann
Intern Med. 2007;146(4):301–6.
4Shanafelt TD, Boone S, Tan L,
Dyrbye LN, Sotile W, Satele D, et al.
Burnout and satisfaction with work-
life balance among US physicians
relative to the general US popula-
tion. Arch Intern Med. 2012;172(18):
1377–85.
5Colwill JM, Cultice JM, Kruse RL.
Will generalist physician supply
meet demands of an increasing and
aging population? Health Aff (Mill-
wood). 2008;27(3):w232–41. DOI:
10.1377/hlthaff.27.3.w232.
6Petterson SM, Liaw WR, Phillips RL
Jr, Rabin DL, Meyers DS, Bazemore
AW. Projecting US primary care
physician workforce needs: 2010–
2025. Ann Fam Med. 2012;10(6):
503–9.
7Huang ES, Finegold K. Seven million
Americans live in areas where de-
mand for primary care may exceed
supply by more than 10 percent.
Health Aff (Millwood). 2013;32(3):
614–21.
8Rittenhouse DR, Shortell SM. The
patient-centered medical home: will
it stand the test of health reform?
JAMA. 2009;301(19):2038–40.
9Starfield B, Shi L, Macinko J. Con-
tribution of primary care to health
systems and health. Milbank Q.
2005;83(3):457–502.
10 Wagner EH, Coleman K, Reid RJ,
Phillips K, Abrams MK, Sugarman
JR. The changes involved in patient-
centered medical home transforma-
tion. Prim Care. 2012;39(2):241–59.
11 Bitton A, Martin C, Landon BE. A
nationwide survey of patient cen-
tered medical home demonstration
projects. J Gen Intern Med. 2010;
25(6):584–92.
12 Raskas RS, Latts LM, Hummel JR,
Wenners D, Levine H, Nussbaum SR.
Early results show WellPoint’s pa-
tient-centered medical home pilots
have met some goals for costs, uti-
lization, and quality. Health Aff
(Millwood). 2012;31(9):2002–9.
13 Patel UB, Rathjen C, Rubin E.
Horizon’s patient-centered medical
home program shows practices need
much more than payment changes to
transform. Health Aff (Millwood).
2012;31(9):2018–27.
14 Annis Emeott A, Markovitz A,
Mason MH, Rajt L, Share DA,
Paustian M, et al. Four-year evolu-
tion of a large, state-wide patient-
centered medical home designation
program in Michigan. Med Care.
2013;51(9):846–53.
15 Harbrecht MG, Latts LM. Colorado’s
patient-centered medical home pilot
met numerous obstacles, yet saw
results such as reduced hospital ad-
missions. Health Aff (Millwood).
2012;31(9):2010–7.
16 Fifield J, Forrest DD, Martin-Peele
M, Burleson JA, Goyzueta J,
Fujimoto M, et al. A randomized,
controlled trial of implementing the
patient-centered medical home
model in solo and small practices. J
Gen Intern Med. 2013;28(6):770–7.
17 Rosenthal MB, Friedberg MW,
Singer SJ, Eastman D, Li Z,
Schneider EC. Effect of a multipayer
patient-centered medical home on
health care utilization and quality:
the Rhode Island Chronic Care Sus-
tainability Initiative Pilot Program.
JAMA Intern Med. 2013;173(20):
1907–13.
18 Rosenberg CN, Peele P, Keyser D,
McAnallen S, Holder D. Results from
a patient-centered medical home pi-
lot at UPMC Health Plan hold les-
sons for broader adoption of the
model. Health Aff (Millwood).
2012;31(11):2423–31.
19 Friedberg MW, Schneider EC,
Rosenthal MB, Volpp KG, Werner
RM. Association between participa-
tion in a multipayer medical home
intervention and changes in quality,
utilization, and costs of care. JAMA.
2014;311(8):815–25.
20 Reid RJ, Coleman K, Johnson EA,
Fishman PA, Hsu C, Soman MP,
et al. The Group Health medical
home at year two: cost savings,
higher patient satisfaction, and less
burnout for providers. Health Aff
(Millwood). 2010;29(5):835–43.
21 Steele GD, Haynes JA, Davis DE,
Tomcavage J, Stewart WF, Graf TR,
et al. How Geisinger’s advanced
medical home model argues the case
for rapid-cycle innovation. Health
Aff (Millwood). 2010;29(11):
2047–53.
22 Baron RJ. New pathways for primary
care: an update on primary care
programs from the innovation cen-
ter at CMS. Ann Fam Med. 2012;
10(2):152–5.
23 Takach M. About half of the states
are implementing patient-centered
medical homes for their Medicaid
populations. Health Aff (Millwood).
2012;31(11):2432–40.
24 Sanford ST. Designing model homes
for the changing medical neighbor-
hood: a multi-payer pilot offers les-
sons for ACO and PCMH construc-
tion. Seton Hall Law Rev. 2012;
42(4):1519–47.
25 Chernew ME, Hong JS. Commentary
on the spread of new payment
models. Healthcare. 2013;1(1–2):
12–4.
26 Baron RJ, Davis K. Accelerating the
adoption of high-value primary
care—a new provider type under
Medicare? N Engl J Med. 2013;
370(2):99–101.
27 Patient-Centered Primary Care Col-
laborative [home page on the Inter-
net]. Washington (DC): PCPCC;
c2013 [cited 2014 Aug 12]. Available
from: http://www.pcpcc.org/
28 National Academy for State Health
Policy. Medical home and patient-
centered care [Internet]. Portland
(ME): NASHP; c2013 [cited 2014
Aug 12]. Available from: http://
www.nashp.org/med-home-map
29 Jackson GL, Powers BJ, Chatterjee R,
Bettger JP, Kemper AR, Hasselblad
V, et al. The patient-centered medical
home: a systematic review. Ann In-
tern Med. 2013;158(3):169–78.
October 2014 33:10 Health Affairs 1831
at BRIGHAM & WOMENS HOSP on October 6, 2014Health Affairs by content.healthaffairs.orgDownloaded from